Common in dancers, and usually tired, overloaded feetStrong evidence
Feet do most of a dancer's work: relevés onto the balls of the feet, pointe for most female ballet dancers, jumps, landings and turns, and in some styles hours in heels or bare feet on hard floors. Across 29 studies of professional and amateur dancers, a review found "a high prevalence and incidence of lower extremity and back injuries, with soft tissue and overuse injuries predominating". In ballet, the foot and ankle accounted for 14% to 57% of injuries, and in competitive ballroom and Latin dancers the foot, ankle and lower leg were the most reported sites.
Injury is uncommon for the hours danced: across 16 studies that counted dance hours, rates were under 5 injuries per 1,000 hours, with no clear difference between recreational, student and professional dancers, and in social salsa, women had about 1.1 and men 0.5 injuries per 1,000 hours. Hip hop and breaking dancers report injuries mostly in the legs. Aches after a long class or a night out are far commoner than injuries that stop dancing.
Sources 1, 2, 3, 4, 5, 6, 7, 8
Heels, pointe and bare feetEmerging evidence
In two professional ballet companies over 3 seasons, women had 1.20 foot and ankle problems needing medical attention per dancer each season, and "Pointe work and jumping actions in women and jumping actions in men were the most common mechanisms of injury". Two thirds of the problems in women built up gradually.
Heels move your weight forward. In 81 lab studies of 1,501 women walking and standing, heels caused "an anterior shift in plantar pressure" (more pressure under the front of the foot) and poorer balance, and in a small treadmill study the load "passed toward the medial forefoot and the hallux" (the inner forefoot and the big toe). A review of everyday wearers linked heels with bunions, foot pain and injuries such as sprains, mostly from low-quality studies. None of these studies was of dancing in heels.
Sources 9, 10, 11, 12
A stress fracture: the one not to missEmerging evidence
In two US ballet companies, 17 of 54 women had had a stress fracture, 63% of them in the long bones of the foot (the metatarsals); dancing more than 5 hours a day and longer spells without periods went with them, an association. The base of the second metatarsal, in the midfoot, is the classic site in ballet: in 51 professional dancers with 64 of these fractures, the pain had come on gradually over about 2 and a half weeks before they sought care. In one Italian ballet school, 19 of 150 trainee dancers had one over 3 years.
A review lists low energy availability (eating too little for your training), low bone density, sudden rises in training and heavy training loads as factors. In an online survey of 247 dancers, 57% of women and 29% of men reported signs of low energy availability. These are reasons to see a GP about bone health, not to stop dancing.
Sources 13, 14, 15, 16, 17
Bunions, the big toe and the second toeMixed evidence
Ballet hasn't been shown to cause bunions: in 63 active and 38 retired ballet dancers, the big toe angle was no greater than in people who don't dance, and a dance review found "insufficient evidence" that pointe work makes bunions more common or worse. In 275 teenage ballroom and Latin dancers who dance in heels, 54.9% had a bunion angle on photographs, girls more often, and in 40 of them the angle grew a little over a year; the study didn't measure heel use, so it shows a link, not a cause.
A second toe longer than the big toe is often blamed for stress fractures, but in 50 elite ballet dancers, toe and metatarsal length were no different in those who had a second metatarsal stress injury.
Sources 18, 19, 20, 21, 22
The tendon behind the inner ankleEmerging evidence
The tendon that bends the big toe (flexor hallucis longus) runs behind the inner ankle bone and works hard on pointe and in relevé. In a surgical series, dancers had waited longer than non-dancers before seeking help, and in 13 ballet dancers whose tendon needed an operation after other treatment failed, all returned to dancing, 11 without restriction. These are small series of the hardest cases; most tendon pain settles without surgery, as our inner ankle pain guide says.
Sources 23, 24
Pointe: readiness, not a birthdayMixed evidence
Guidance from dance medicine clinicians suggests starting pointe after about 4 years of ballet training, for students who started at 8 or older and take class at least twice a week, with good trunk and leg control and enough ankle and foot range; it discourages pointe for students who take ballet once a week. Pointe usually starts between 11 and 13. A review found no validated screening test and no tested pre-pointe programme, and the American Orthopaedic Society for Sports Medicine says age 12 is the usual lower limit, but "strength and maturity are more important than age". Your teacher decides.
Sources 25, 26, 27, 28, 29
When it isn't dancing: the causes the warning signs cover
Some foot pain has causes dancing didn't create, and the warning signs follow the pages behind them. The NHS sprains and broken ankle pages ask for a same-day check if you can't put weight on the foot, and say a very high temperature or feeling hot, cold or shivery with it could be an infection; the NHS cellulitis page covers a hot, swollen, painful foot, and its 999 signs are those of sepsis. A sudden hot, red, swollen joint can be gout, the NHS says, or a joint infection, which the NHS septic arthritis page says needs urgent treatment. A snap at the back of the heel can be an Achilles tendon rupture, as an NHS hospital's leaflet describes, and a foot that is suddenly cold and pale is the emergency the NHS peripheral arterial disease page describes. With diabetes, the National Institute for Health and Care Excellence (NICE) asks for a new foot problem to reach a specialist foot team quickly.
One spot on a foot bone that hurts with every step, and later at night, can be a stress fracture, as Health New Zealand and the American Academy of Orthopaedic Surgeons (AAOS) describe; some sites, such as the middle of the foot, heal less well and need prompt assessment, two reviews of high-risk stress fractures say. A podiatry consensus on sesamoid pain advises padding to take the load off the sesamoids, and referral when a stress injury or fracture is suspected. One NHS trust advises seeing a doctor for Morton's neuroma pain that lasts 3 months despite changing shoes and using insoles. Bone pain that is constant or worse at night needs checking, the NHS bone cancer page says, though that is rare. And more than one stress fracture, periods that stop, or eating too little for your training needs a GP: the International Olympic Committee calls this relative energy deficiency in sport (REDs), an Endocrine Society guideline covers periods that stop, and an NHS trust's leaflet covers caring for a stress fracture.
Sources 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67
When a scan helps, and how it usually goesEmerging evidence
Most foot pain after dancing needs no scan. An X-ray is for a bone that may be broken: the NHS broken toe page, for example, says a GP may send you for one if pain and swelling haven't started to ease 5 days after the injury. A suspected stress fracture is the main reason for imaging, but an early X-ray can look normal: in the 64 second metatarsal fractures above, the first X-rays were negative in 42. A trainee series advises diagnosing early "through clinical examination and then through X-ray and MRI" (magnetic resonance imaging), which shows the fracture and how far along it is.
Aches settle in days. In a UK ballet company, the average injury that stopped dancing cost 7 days; in two professional companies, foot injuries that stopped dancing cost a median of about 3 weeks; and ankle sprains in teenage ballroom and Latin dancers cost a mean of 11.2 days. Dancers with a second metatarsal stress fracture performed again at an average of 6.2 weeks after diagnosis, all without surgery, though 14% had some midfoot aching later. A spiral fracture of the fifth metatarsal took more than 6 weeks to heal in 1 in 3 people in a general trauma clinic. A past injury is the clearest risk factor for the next, so a full return matters. No one can promise a date.
Sources 14, 15, 30, 31, 9, 32, 33, 24, 34
